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My Health Claim Was Denied; Now What? Part 2: Filing an Appeal

Far too often, when insurance companies deny medical claims the results are far-reaching. A post-treatment denial may leave a family facing overwhelming out-of-pocket medical bills. While, pre-treatment claim denials may cause a patient to not seek life saving or life-altering care.

If your insurance company has denied a medical claim, you have the right to appeal the decision. To exercise this right, you must complete several key steps in the appeals process, including completing and filing paperwork, gathering documentation and providing additional information to your insurer as part of the appeal.

Completing the Necessary Forms

To initiate an official review of your claim, you must complete and file all paperwork required by your insurance company. Each company’s paperwork requirements are different, but most will require you to submit several forms, including an Appeal Request form.

Creating a checklist of the required paperwork may help you keep track of each form’s completion and submission. It may also be helpful to have your policy information, claim number and insurance ID number at hand when completing paperwork.

Gathering Documentation

To file the most effective appeal possible, you must first gather several documents, including:

  • Explanation of Benefits: Your explanation of benefits (EOB), a standard form sent by the insurance company whenever your claim is approved or denied, uses codes to explain how the company arrived at its decision. Most EOBs will also provide a key to the codes, so you can find out what they mean. If you still aren’t sure why the claim was denied, call the company and ask. You have a right to this information, and the insurer has a responsibility to explain it in terms you can understand.
  • Medical Records: Make sure you have all the evidence to show that the services you want covered are medically necessary. Referrals, prescriptions from your doctor and any relevant information about your medical history may help your claim get approved the second time around. Sometimes, a follow up call by your physician or clinic’s business office can resolve the problem, especially if your medical records were not properly submitted with the initial claim.
  • Medical Plan or Summary Plan Description: Next, you want to get a copy of your medical plan to understand covered benefits and any limitations to coverage. If you purchased the coverage, you should obtain a copy of your plan. The medical plan is often found on-line or you can contact customer service. If your medical benefits are through your employer, you need to obtain a copy of the Summary Plan Description through your Human Resource Department or on-line.
  • Internal Medical Policies or Guidelines: Your insurance company’s internal policies or guidelines may play a role in the denial of your claim. These policies and guidelines may provide insight on the company’s stance of experimental treatments, acceptable levels of care and other treatment issues. Obtain a copy of the internal policy that gives reasons for their position.

By law, your medical provider or insurance company must provide copies of these documents. Contact them directly for assistance.

Submitting Additional Information

When initiating the appeals process, you can submit any additional information you want the insurance company to consider, including:

  • Missing documents: Many insurance claims are denied due to missing or incomplete paperwork filed by your insurance provider. Obtain all paperwork related to the treatment and compare it against the information submitted with the initial claim.
  • Letter from your physician: Many physicians are willing to write a letter detailing your medical condition, the treatment provided and the reasons behind the treatment. This information may help your provider reconsider the claim.

There is no limit to the additional information you may submit. Just be sure that all additional information provided is clear, concise, accurate, and pertinent to the treatment or claim in question.

We Can Help

The process of appealing a denied claim can be time-consuming and frustrating. It doesn’t have to be. Our health insurance claims attorneys are available to help with all steps in the process. We have the skills and experience needed to help you maximize your chances of obtaining a favorable ruling following an appeal.

To learn how we can help you successfully file your appeal, call (651) 788-0236 or contact our firm online today.

Disclaimer: The information in this blog post (“post”) is provided for general informational purposes only, and may not reflect the current law in your jurisdiction. No information contained in this post should be construed as legal advice from Wrobel & Smith, PLLP or the individual author, nor is an attorney client relationship established. This post is not intended to be a substitute for legal counsel on any subject matter. No reader of this post should act or refrain from acting on the basis of any information included in, or accessible through, this Post without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer licensed in the recipient’s state, country or other appropriate licensing jurisdiction.

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